1Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, London WC1E 8HT

2Andrey Rylkov Foundation for Health and Social Justice, Moscow, Russia

3Social Medicine, University of Bristol, Bristol

Correspondence to: T Rhodes tim.rhodes{at}lshtm.ac.uk

Accepted 2 June 2010

Despite good evidence for its effectiveness in HIV prevention, countries such as Russia remain resistant to harm reduction. Tim Rhodes and colleagues show the obstacles to and potential benefits of changing policy on opiate substitution treatment

The health harms of injecting drug use include HIV, hepatitis C, bacterial infections, overdose, and substantial excess mortality. An estimated 16 million people inject drugs worldwide, 3 million of whom live in eastern Europe.1 Around 1.5 million people are infected with HIV in eastern Europe, with most infected through injecting drug use.2 The largest European epidemics are those in the Russian Federation and Ukraine, where over a third of injecting drug users are thought to be HIV positive.12 One contributing factor is policy resistance to harm reduction.

Epidemiologist Elizabeth Pisani and other leading commentators describe which countries are leading the way in tackling HIV infection among injecting drugs users in this 10 minute BMJ video.

Harm reduction

Harm reduction encompasses interventions and policies that seek primarily to reduce the harms of drug use without necessarily requiring abstinence from drug use. The Council of the European Union, World Health Organization, and United Nations Joint Programme on HIV/AIDS recommend a comprehensive package of harm reduction services for people who inject drugs, including programmes providing easy access to clean needles and syringes, opioid substitution treatment, and antiretroviral drugs for HIV.3 Access to opioid substitutes and syringe distribution programmes can reduce risky injecting practices and incidence of HIV.456 Opioid substitution also reduces deaths from overdose, drug related mortality, and offending. Access to antiretroviral HIV treatment improves mortality and morbidity among injecting drug users.7

A critical factor determining the effect of interventions is their coverage among target populations.8 Intervention coverage varies widely globally but is especially low in eastern Europe, where …